Men's Social Connectedness - Beyondblue

Table of Contents 1.

EXECUTIVE SUMMARY ............................................................................................................ 5

2.

BACKGROUND........................................................................................................................ 10

3.

2.1.

Research background ....................................................................................................... 10

2.2.

Objectives ......................................................................................................................... 11

2.3.

Methodology ..................................................................................................................... 12

SOCIAL CONNECTEDNESS IN AUSTRALIA ......................................................................... 18 3.1.

What’s the relationship between social support and mental health? ................................. 18

3.2.

Profiling social connection in Australia .............................................................................. 22

3.2.1. Are men aware of the issue of social disconnectedness? ......................................... 22 3.2.2. How important an issue do men feel social disconnection is?................................... 25 3.2.3. How does the social connectedness of men vary across the population?................. 26 3.2.4. How many interactions do men have, and what is the quality of these interactions? 28 3.2.5. How satisfied are men with their level of social connectedness? .............................. 30 3.2.6. What is the impact of connections with the community? ........................................... 31 3.3. Social connectedness segments ....................................................................................... 32 4.

BARRIERS AND FACILITATORS TO SOCIAL CONNECTION ............................................... 38 4.1. What are the patterns and behaviours relating to men’s emotional engagement with friends, and does this meet their needs? ...................................................................................... 38 4.1.1. How do men typically form friendships? .................................................................... 38 4.1.2. How do men experience social disconnection, and how does this change as they move through their middle years? ............................................................................................ 42 4.1.3. Why are they dissatisfied? ........................................................................................ 45 4.2. Drivers of social connection and disconnection................................................................. 51 4.2.1. Does men’s socialisation and conformity to male stereotypes and cultural norms impact on their experience of social connections? ................................................................... 51 4.2.2. Are high levels of self-stigma and low levels of help-seeking behaviour associated with lower social support? ........................................................................................................ 55 4.2.3. How do life events impact on men’s social support and connectedness? ................. 58 4.2.4. Does employment status affect social connectedness? ............................................ 62 4.2.5. How does resilience interact with satisfaction and connectedness? ......................... 63 4.3. Practical barriers ............................................................................................................... 64 4.3.1. How do financial restraints impact on experiences of social connection? ................. 64 4.3.2. Does men’s health impact on their social connectedness? ....................................... 65 4.3.3. Practical barriers for trans* men ................................................................................ 67 4.3.4. Practical barriers for intersex people ......................................................................... 67 4.4. What is the role of the internet and social media in connectedness? ................................ 68

5.

2

INTERVENTIONS .................................................................................................................... 72

5.1.

What activities or interventions might facilitate social support? ......................................... 72

5.1.1. What social skills might facilitate connectedness? .................................................... 72 5.1.2. What specific interventions might work to improve social connectedness? ............... 74 5.2. What are the barriers preventing men from joining groups or programs to improve their social support? ............................................................................................................................. 80 6.

RECOMMENDATIONS AND NEXT STEPS ............................................................................ 84 6.1.

Raising awareness ............................................................................................................ 84

6.2.

Programs and tools ........................................................................................................... 85

6.2.1. Helping others/volunteering....................................................................................... 85 6.2.2. Promoting community involvement ........................................................................... 85 6.2.3. Building resilience in men ......................................................................................... 85 6.2.4. Online tools ............................................................................................................... 86 6.2.5. A group facilitator role ............................................................................................... 87 6.2.6. Broadening the base for Men’s Sheds members ...................................................... 87 6.3. Subgroup suggestions ...................................................................................................... 88 6.3.1. Trans* ....................................................................................................................... 88 6.3.2. Intersex ..................................................................................................................... 88 6.3.3. ATSI (Aboriginal and Torres Strait Islander peoples) ................................................ 89 6.3.4. CALD (Culturally and Linguistically Diverse) ............................................................. 89 6.3.5. Age............................................................................................................................ 89 6.3.6. Sexuality ................................................................................................................... 89 6.4. Next steps ......................................................................................................................... 92 7.

APPENDIX ............................................................................................................................... 95 7.1.1. The segmentation analysis ....................................................................................... 95 7.1.2. Model factors............................................................................................................. 98 7.2. Ethnographic case studies and boards ............................................................................. 99 7.2.1. Ethnographic Case Studies ....................................................................................... 99 7.3. Knowledge Audit ............................................................................................................. 116

3

4

1. EXECUTIVE SUMMARY Research background Past studies1 have shown that social connectedness may be a protective factor against depression for Men in their Middle Years (30-65; hereafter ‘men’). Recognising that men often find it difficult to maintain social connections throughout their middle years, beyondblue, proudly funded by The Movember Foundation, commissioned this research to understand how men perceive and experience social connectedness, to identify the trigger points and pathways that lead them to lose social connections and to highlight tools that may help them develop stronger ties. The project adopted a multi-stage, multi-method approach, consisting of: a review of existing literature and interviews with thought leaders and practitioners; 14 qualitative discussion groups; a robust quantitative online survey with 4100 men; online discussion boards with small groups of trans* and intersex people who identify as men and another, larger group of ‘socially vulnerable men’ and, finally, 13 ethnographic case studies. The broader experience of social disconnectedness There is a widespread expectation that men in their middle years will experience dissatisfaction with their social lives at some point. Almost seven in ten (69%) agreed that most men will go through a lonely period at some stage, and almost two-thirds (63%) agreed it is normal to lose touch with your friends as you get older – indeed those men who don’t go through a lonely patch and manage to maintain contact with friends are in the minority. Nearly a quarter of men (23%, approximately 1.1 million men) in their middle years score low on the Duke Social Support Scale and may be at risk of isolation. Another half of men in their middle years (45%, approximately 2.2 million men) have medium social support. Further:  Social support appears to dip between the ages of 35 and 54, with respondents outside this age band reporting higher levels of social support.  One quarter (25%) of men have no one outside their immediate family whom they can rely on.  Over one in three men (37%) are not satisfied with the quality of their relationships, typically because they do not feel they are emotionally connected or supported.  Men who feel like they are part of a community are more likely to have strong social support overall. Despite this relatively normalised experience of social disconnection, lack of social support/loneliness were seen as unimportant compared to other, highly correlated (and indeed E.g. Davidson SK: Social Connectedness and its association with depression outcome among primary care patients. Dissertation Melbourne: University of Melbourne; 2013. 1

5

probably causally related), social issues such as suicide and depression. This is an unspoken phenomenon: those experiencing it would rarely feel able to bring their ‘neediness’ up in conversations and it is rarely, if ever, a topic of public discourse. These men often lack the skills, the pathways and frequently the drive to remedy their lack of social connection and instead tend to bear the misery and shame of their situation with a stoic, masculine pride. Social connectedness is clearly an issue for Men in their Middle Years, and, given the association with mental health issues, this research provide evidence that the issue is worthy of substantial support. Drivers and barriers to social connectedness Social connection is a complex issue and there are a range of factors including underlying predispositions as well as situational triggers that explain the phenomenon of men experiencing poor social connections in their middle years. Key findings were:  The men who had experienced periods of loneliness were likely to have friendships based on a common interest or purpose, and contact with friends fell away as participation in these groups (e.g. sporting clubs) ceased.  A majority (61%) have lost contact with more friends than they would like in the past few years.  Changes in family circumstances, injury, illness, mental health, finances, change in work circumstances and simply not having the time to maintain relationships were all seen as contributing to the path of becoming dissatisfied with their level of social connectedness.  Recognising that the unemployed may be particularly at risk of poor social connectedness will help to target men who may be at risk.  Men who had experienced low levels of emotional openness or engagement with their fathers growing up are more likely to experience poor social support, and good communication between father and son may be a protective factor from social disconnectedness in later life.  Men also face practical barriers (e.g. financial and health) to increasing their social connections, and any programs need to be understanding of the particular financial restraints and health barriers faced by many of these men. This includes illness and disability, which may be a trigger for poor social connectedness. Many men want greater openness with their friends and to be able to talk about personal problems, but admit they don’t always have the skills or tools to initiate these conversations, or understand how to respond when a friend opens up to them. Specifically:  Half of men (50%) claim to rarely talk about deeper personal issues with friends, while nearly a third (31%) don’t spend much time talking with their friends in general.

6



Almost a third of men (31%) wish that they could open up more to their friends and a similar proportion (28%) want friends to open up to them in return.

Suggested interventions programs and tools To successfully address the problem at a broader community level, there may be merit in putting social connectedness on the agenda. Rather than framing social isolation as a pathway to psychological distress, beyondblue could emphasise its importance as a protective factor. Encouraging men, their partners and the community more broadly to take proactive steps to support strong social connections is a positive message for beyondblue to champion. Social connectedness is not seen as an important social issue by men, and the link to other social issues is not readily recognised or understood. beyondblue could facilitate understanding of the association between social connectedness, suicide and depression, further highlighting this important social issue. Other suggestions include:  Helping men to build resilience via programs and training for those in danger of becoming disconnected (e.g.: recently unemployed). This has dual benefits – reducing psychological distress, and increasing their ability to maintain and grow relationships through tough times.  Helping guide men into a variety of social channels. In this way, men can initiate new relationships with like-minded individuals over a shared or common purpose, which will also help provide the relationship ‘breadth’ from which ‘depth’ can be built.  Helping men initiate, conduct and ‘own’ conversations concerned with personal and emotional issues. Focusing this on how to offer support (while subtly demonstrating acceptable ways of asking for support) is likely to be a more powerful approach.  Reminding men (and the women in their lives) that men need social connections. Public acknowledgement of the importance of social connectedness, the need to devote some time to improving and developing male-male relationships.  Programs and tools to help men develop stronger, more robust community networks. The model of the Men’s sheds appeals to men in their middle years, but it is perceived an activity targeted at older men. beyondblue could play a role in helping Men’s sheds broaden their base and encourage younger members to join. Successful examples of men’s groups abound: from Hacker/Maker communities to ‘multi-sport’ groups and even loose, but broadly inclusive and diverse groups of locals who get together once a month to discuss ‘important men’s business’ at the local watering hole; similarly, there are opportunities to help groups like this expand into other locations. A new member facilitator, with whom men could meet prior to joining a group, was very compelling for our less connected men; beyondblue could play role in providing materials and training; further, a

7

general member facilitator for groups, clubs and teams, for to keep injured, retired or otherwise distanced members connected to the groups will help keep men from becoming disconnected. While online connections were not felt to be a true alternative for in-person contact, there are nevertheless opportunities to provide men with online tools to improve their social connections through improving both the quality and closeness of connections (depth), and the number of connections (breadth). Specifically, there is a need for:  Online tools to guide men through the process of finding and joining appropriate groups and to provide insight into what the experience may be like, making the process less daunting.  Tools, tips and lessons to help them provide emotional support. This could include tips and examples of how to approach, initiate and maintain difficult, potentially confronting conversations. It should also demonstrate how to provide support for friends or family, and help them identify when, where and how that support might be needed. Different cultural norms are likely to have a strong impact on men’s ability to maintain social connection, and this will need to be taken into account when designing programs for a multicultural society like Australia.

8

9

2. BACKGROUND 2.1.

Research background

Depression is a highly prevalent and disabling condition and represents the greatest single burden of any non-fatal disease in Australia (Mathers et al, 2000)2. People with depression suffer significant psychological distress, experience impairment across all aspects of their lives and are at increased risk of suicide (Harris & Barraclough, 19973; Patton et al 20104). Men in their middle years are particularly at risk of suicide and, as such, are the focus of beyondblue’s current initiative, with support from The Movember Foundation. A considerable body of research indicates that social connectedness is a protective factor against depression (Kawachi & Berkman, 2001)5. People with higher levels of social connectedness are less likely to develop depression and, if they do develop depression, they are less likely to experience persistent and recurrent episodes (Davidson, 20136; Teo et al). Their research suggests that strengthening social connectedness among men in their middle years may reduce the incidence of depression which, in turn, may reduce the risk of suicide. Empirical research789 indicates that social connectedness can be conceptualised as comprising three independent domains: 1. Attachment Relationships – indicates the availability of close relationships, e.g. spouse, children, siblings 2. Integration – indicates the degree to which an individual is immersed in a social network and the broader community 3. Perceptions – indicates an individual’s subjective appraisal of the adequacy of their social connectedness, such as their level of satisfaction with their social connections.

Mathers CD, Vos ET, Stevenson CE, Begg SJ: The Australian Burden of Disease Study: Measuring the loss of health from diseases, injuries and risk factors. Medical Journal of Australia 2000, 172(12):592-596. 3 Harris EC, Barraclough B: Suicide as an outcome for mental disorders: A meta-analysis. British Journal of Psychiatry 1997, 170:205-228. 4 Patton GC, Coffey C, Posterino M, Carlin JB, Bowes G: Life events and early onset depression: cause or consequence? Psychological Medicine 2003, 33(7):1203-1210. 5 Kawachi I, Berkman LF: Social ties and mental health. Journal of Urban Health 2001, 78(3):458-467. 6 Davidson SK: Social Connectedness and its association with depression outcome among primary care patients. Dissertation Melbourne: University of Melbourne; 2013. 7 Davidson SK: Social Connectedness and its association with depression outcome among primary care patients. Dissertation Melbourne: University of Melbourne; 2013. 8 Duncan-Jones P: The structure of social relationships: Analysis of a survey instrument. Social Psychiatry & Psychiatric Epidemiology 1981a, 16(2):55-61. 9 Blazer DG: Social support and mortality in an elderly community population. Chapel Hill, NC: University of North Carolina; 1980. 2

10

The last of these, which measures people’s perceptions of whether they have somebody they can talk to about things that matter to them, has been shown to be most strongly correlated with mental health issues. The evidence points to the importance of strengthening existing ties, not just building new ones – though for some there will be a need to build broader social integration so as to enable improvements in the quality of relationships. While there is a considerable body of academic literature examining the impact of social connectedness on mental health, including a focus on men, this has not necessarily been developed with specific, practical intervention outcomes in mind.

2.2.

Objectives

beyondblue has developed its expertise in taking macro sociological issues and bringing these into the personal domain, so as to be able to effect real change. This research built on the existing literature, but the focus is the perspective of men themselves – how they perceive and experience poor social connectedness, the trigger points and pathways that lead them there and, crucially, the interventions (such as programs or tools) that have helped them, or which might have a real impact in the future. The objectives of the project were to:  Identify the barriers impacting the social connectedness of Men in their Middle Years;  Identify the factors which facilitate social connectedness of Men in their Middle Years and have a positive impact on their mental health;  Point to specific enabling strategies for Men in their Middle Years to connect socially; and  Provide any other information which could help inform the design and approach of future social connectedness initiatives for Men in their Middle Years.

11

2.3.

Methodology

The project adopted a multi-stage, multi-method approach to reach the projects aims. Stage 1: Knowledge audit The knowledge audit informed the subsequent phases of the research by refining the scope of the research and specific research questions. The knowledge audit ensured that the study built on current knowledge and understanding. The first step was to review relevant academic and ‘grey’ literature, targeting reports which evaluate the effectiveness of interventions. This included formal and informal evaluations of programs, projects and strategies aimed at increasing social connectedness. Men in their middle years were the focus, although programs targeting the general population, women, and other age groups were included where relevant to explore underlying themes and identify gaps in programs targeting men. In total, 45 documents from five countries and a range of perspectives were covered. Also investigated in detail were eight relevant strategies aimed at improving social connectedness. Experts from Australia, the U.K. and the U.S. were interviewed about their work and thoughts on social connection, and interventions in particular. The seven interviews took the form of qualitative depth interviews (up to 45 minutes each in duration) and were conducted by our most senior project team members. The interviews were conducted with individuals who were identified as able to provide key, relevant insights into social connectedness, with views on possible strategies for improving connectedness. The perspectives/organisations interviewed were: Meds/       

Men’s Sheds/University of Ballarat Men’s relationship counsellor Alcoholics Anonymous National Seniors Australia Sporting Organization Samaritans UK Sign For Work

Stage 2: Qualitative discussion groups The purpose of the discussion groups was to take the ‘macro sociological perspective’ of much of the literature and translate this into what it means at the level of the lived experience of the individual – with the very practical rationale that beyondblue needs access to the personal narrative in order to be able to discern and hone potential opportunities for interventions. The qualitative findings informed the quantitative stage of the research (stage 3).

12

Fieldwork was conducted between 20th Feb and 5th March 2014 and included 11 group discussions with men aged between 30 and 65 and 3 group discussions with women of the same age. The men who participated had experienced feeling intensely lonely and disconnected from others but were now in a better place and no longer felt so alone. Men with wide-ranging life experiences participated, including those who had been through separation, custody battles, financial strains, job loss and retirement or other triggers that led them to feeling socially disconnected. The women in the groups had a close friend/ex-partner or family member whom they saw as being socially disconnected. The groups were held in Melbourne metro, regional VIC, Sydney metro, regional NSW and Brisbane metro locations. Participants included culturally and linguistically diverse (CALD) individuals and represented low, mid and blue-collar socio-economic backgrounds. We also conducted two groups with unemployed men and two groups with homosexual/bisexual men. The groups covered:  General orientation to the topic of social connection  Retracing the journey that led to them feeling alone and/or disconnected  The language and conceptual frameworks men use to discuss and make sense of the experience of social disconnection and loneliness  Identification and evaluation of interventions and ways to help get men back on track Stage 3: Quantitative Survey This phase was designed to allow the depth of insight garnered at previous stages to be tested with the broader population of Males in their Middle Years, and set in place a solid empirical foundation on which to base interventions designed to help with social connectedness. Fieldwork was conducted between 28th March and 14th April 2014, with 3750 men aged between 30 and 65 across Australia (in metro, regional, rural and remote locations). Boost samples of 300 men aged between 18-29 and 50 Aboriginal and Torres Strait Islander (ATSI) respondents were also collected during fieldwork. All respondents completed a 20 minute online survey. Further details about the method are included below. Methodology Data was collected online, in order to reduce social desirability bias, increase representativeness and sample size, and allow for a longer survey without compromising data quality. Multiple providers were used to minimise panel bias.

13

Sampling The quantitative survey was based on a large sample of men aged 30 to 65 years, nationally representative by age (seven five-year age brackets), state/territory and location (metropolitan, regional and rural).10 A ‘comparison sample’ of those aged 18-29 years was also included to unpack what happens between the two age bands to drive lower levels of social connectedness. A boost sample of 50 ATSI respondents was also included. The following quotas were placed on our survey: Figure 1 : Sample Quotas

Age bracket 30-34

Proportion of sample

Number of interviews

15% 14% 15% 14% 14% 13% 14%

551 528 569 531 532 501 538

100%

3,750

35-39 40-44 45-49 50-54 55-59 60-65 Total State/Territory



ACT NSW NT QLD SA TAS VIC WA

2% 32% 0% 20% 7% 2% 25% 11%

78 1210 12 762 266 77 949 396

Total

100%

3,750

And further, by remoteness area:

10

Age bracket



A capital city A regional centre

68% 20%

2551 751

Australian Bureau of Statistics (2013). Estimated resident population by age and sex at 30 June 2012 (3101.0).

14

A country town A rural or remote locality

9% 3%

349 99

Total

100%

3,750

Questionnaire The questionnaire was developed by Hall & Partners | Open Mind in collaboration with beyondblue. It included validated instruments for depression and anxiety and drew on the existing literature for questions around social connectedness to ensure that findings were robust and useful. The questionnaire used the insights from the qualitative phase, and covered:  Awareness of social issues  Measures of social support  Experience of life events  Formation of friendships  General attitudes (help-seeking, stigma, adherence to male stereotypes)  Interventions and barriers  Demographics Analysis Data was weighted to region, age and state using figures from the Australian Bureau of Statistics 2011 Census of Population and Housing. Significance tests were conducted at the 95% confidence level. A number of high-level statistical techniques, including segmentation analysis and structural equation modelling, were applied to the data. Stage 4: Ethnographic exploration Ethnographic case studies were conducted to explore and bring to life the segments identified in the quantitative stage. Each of the 13 ethnographies consisted of an initial set-up meeting, a video diary where the men recorded typical social interactions and how they were feeling during the day, and then a one hour depth interview, which explored their experiences in detail. A total of six trans* and six intersex individuals who identified as male participated in two separate online forum/bulletin boards over a three day period. The participants were recruited through beyondblue’s networks and had various levels of involvement in the trans* and intersex communities. This relatively low number of participants is explained by the difficulties commonly found in recruiting

15

this group11. Alternate strategies are typically adopted to engage with trans* and intersex individuals, hence the online forums approach. An online bulletin board of men with lower DSSI scores and high K10 scores ran over three days on our proprietary platform YourWord™ between 20th and 22nd May 2014. It sought to further uncover the experience of the most vulnerable and explore the impact of additional program and strategy ideas developed during earlier stages of research.

11

Leonard, W., Pitts, M., Mitchell, A., Lyons, A., Smith, A., Patel, S., & Barrett, A. (2012). Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. Monograph Series Number 86. Melbourne: The Australian Research Centre in Sex, Health & Society, La Trobe University.

16

17

3. SOCIAL CONNECTEDNESS IN AUSTRALIA 3.1.

What’s the relationship between social support and mental health?

Summary: This research confirmed the relationship between social connectedness and psychological distress. Poor social connectedness is correlated with higher levels of depression and anxiety symptoms. Whilst resilience is the most important preventative factor against psychological distress, satisfaction with relationships – which is positively driven by social support and negatively via social drift – is shown here to be an important preventative factor. Detail: The online discussion board with vulnerable men shed light on the link between poor social connections and mental health issues. Many of these men believed their mental health issues were often the cause (or at a least strong driver) of their experiences of poor social connection. “Sadly at the moment I cannot work due to anxiety, social panic attacks. I have suffered from Depression for a long time… I guess because of what has happened it has made me anti-social and not want to be around people…” “Struggle badly with depression and anxiety… at home by myself most of the time (wife works) and feel very alone and worthless these days. No longer work (Disability Pension) and all my old mates have either moved away or died. Used to have good self-esteem but not anymore with not earning money, not driving, sporting skills gone” “Mental health issues stand in the way. Arguably poor friendships and family resulted in a mental health diagnosis, but also could be that diagnosis resulted in lost friendships” “A major suicide attempt on my part cost me many (about 70%) of my friends and made family members hostile” “Social phobia - I personally try hard to be sociable, only to be given the feeling that I'm outright rejected by most of whom I talk to”

18

The Kessler Psychological Distress Scale, or K10, is a validated checklist measuring depression and anxiety, or psychological distress. Given the link between social connection and mental health problems, the K10 checklist was included in the quantitative survey to further explore this relationship among Men in the Middle Years. Almost six in ten (59%) of men had K10 scores indicating low depression and anxiety, and just under one in five (17%) or around 830,000 men in Australia had scores related to very high signs of depression and anxiety12. Figure 2: K10 scores

It was hypothesised that the relationships between social connectedness, psychological distress and resilience would be strong, and our findings show that these are indeed highly correlated. Figure 3 shows that men with low social support (low DSSI scores) are more likely to be experiencing very high psychological distress. Men with strong social support are more likely to have low levels of psychological distress. Figure 3: K10 scores by social support scores

12

The breaks used: Low (scores 10-19), Moderate (scores 20-24), High (scores 25-29), Very high (scores 30-50)

19

The significant (p